Many are linking to this story around the blogosphere and I encourage everyone to read it. In it, a Ob/Gyn describes her emergency care of a woman who arrived in her ED in hemorrhagic shock from a botched illegal abortion. Though clearly it was touch and go and there was some panicky action, our heroine thought fast and saved a life. My mother once worked in a labor and delivery ward to put herself through medschool in the days before Roe v Wade and this type of situation was common.
This is a great story because it illustrates two points. One, the war on abortion by the right wing is futile. We know abortion is more common where it is illegal and cases like these are more common. Banning abortion does not save lives. It results in more abortions, and more lives lost. Worse, in countries with strict bans even treatment of ectopic pregnancy is forbidden where there is still a beating heart detected by ultrasound. Doctors in these countries can literally go to jail for saving a woman’s life, all for the sake of a non-viable embryo that will kill the mother. The hypocrisy of calling this position pro-life is demonstrated by cold hard data. More women die. More fetuses are aborted.
Second, it shows how a well-trained doctor can save a life with some quick thinking. Hemorrhagic shock is something I’m pretty familiar with after my second year rotation in Shock Trauma, and in a few spectacular cases of bleeding on the wards. There are many times when as a doctor you think you’ve probably saved a life. Every case of appendicitis, dropped lung, or kid with a gastroschisis technically is a save but situations like those don’t have quite the same visceral terror and immediacy of someone who is bleeding to death right in front of you. It’s hard to keep a cool head when you’re elbow deep in a pool of blood. One case in particular that sticks out in my mind was during a nice calm Saturday in the fall. I had just finished assisting in an open appendectomy and was doing my usual neurotic repetitive rounds through the ICU I always did when I was on call. At this particular hospital, when on call I was responsible for all ED surgical consults, all the surgical floor patients, as well as the surgical ICU (I had to carry 4 pagers). So since I’d been in this case for the last hour or so I decided to check in with the ICU folks. It wasn’t the sickest ICU I’ve ever worked, nothing like the U Maryland Surgical ICU or Cardiac Surgery ICU, but, like the ocean, it’s never a good idea to turn your back on the ICU patients. So, I was passing by one patient’s room and I seen on the monitor a blood pressure of 60/40…
I was lucky, I just happened to be passing by right when this guy’s pressure dropped, before the nurses even had time to page me.
Here’s some history. He was in his 60-70s, a vascular patient with diabetes, hypertension, dyslipidemia, the usual set of comorbidities you see in people after decades of cigarette smoking and high blood sugars. He was in the hospital because he had received a vein graft in his leg a month before but he had unfortunately gotten a surgical site infection. The graft, which was meant to bypass a blocked artery in his leg so he wouldn’t lose his foot or need a below-knee amputation, was still open and working. He had been admitted in septic shock, had acute kidney injury from the shock, and required resuscitation and placement of a large catheter in his subclavian vein so we could perform dialysis. This, sadly, is not particularly uncommon with this patient population. Diabetics and smokers are terrible at healing wounds, and are very prone to infection. His had run rampant, and he had a resistant psuedomonas strain isolated from his blood (also common in diabetics) which was ominous indeed. After stabilization and debridement of his wound he was relatively stable, hanging out in the ICU, and about to be transferred to the floor.
Now, I’m looking at a pressure of 60/40, he’s currently hooked up to the dialysis machine and the nurse has already stopped dialysis and bolused him 500cc of normal saline (wimpy I know, but they’re more timid with dialysis patients). I ask, “what’s going on here?” and the dialysis nurse just says he suddenly dropped his pressure, no idea why. This is not an uncommon event on dialysis but usually the hypotension dialysis patients get isn’t so severe.
So, what do you do in a patient like this? In medicine we usually apply what we call the “ABC’s”. Airway, Breathing, Circulation, followed by a rapid exam. The patient was alert and talking (amazingly), and said he thinks he wet the bed. He was oxygenating ok with a O2 sat in the 90s so that takes care of A and B. For circulation we started bolusing IV fluids through his quinton catheter as fast as we could squeeze them in. This took all of 5 seconds with a good ICU nurse at the bedside. Then the nurse pulled the sheet off the patient so we could get a look at him and we saw the problem. He was sitting in a pool of blood an inch deep. It was probably between 30-50% of his blood supply in the bed, and from his surgical incision, just alongside his knee blood was pumping out in arterial spurts. The infection had compromised the integrity of the graft, and now we had catastrophic bleeding.
No time to lose I grabbed his knee in a death-grip, holding the exploded vein graft shut with two fingers. A lot of people in the face of massive bleeding make the mistake of piling gauze on a bleed. This does nothing to achieve hemostasis. Direct digital pressure to a bleeding site is the way to go.
Another piece of luck, the anesthesiologist and my chief resident were still in the building because of the appy. A few quick pages and a stat blood order later we were off to the OR with me riding on the bed so I could fit through the doors without having to let go of his leg.
Ultimately he lived, his kidneys recovered and he went home.
Hemorrhagic shock is one of those situations where the adrenaline flows but if you remember your training and follow some basic rules of resuscitation it’s highly amenable to treatment. We can always put blood back in, but you have to find the bleeding and arrest it quickly to save the life. Dr. Gunter knew this, and her expertise allowed her to save the life of an unfortunate young woman that would have never been in that position if contraceptives were easily available and if her abortion had been safe and legal. If we are honestly concerned about the preservation of life, we must divorce ourselves from emotion over this issue and accept the data that clearly shows restricting abortion does not prevent it, only increased access to contraception will lower abortion rates.